Synopsis In the afternoon of 13 October 1993, the CAPE BRIER was fishing off the south coast of Newfoundland. As the vessel rolled in a beam sea, a trawl door that came loose from its stowed position struck and fatally injured a crew member. At the time, the crew member was attending the haul-back of the trawl net which was being brought on board the CAPE BRIER in near-gale weather conditions. The Board determined that the trawl door on the CAPE BRIER came loose because it had not been adequately secured against the vessel's movement in the sea conditions in which she was operating. 1.0 Factual Information 1.1 Particulars of the Vessel CAPE BRIER Official Number - 392729 Port of Registry - Halifax, Nova Scotia Flag - Canadian Type - Stern trawler of steel construction Gross Tons - 992 Length (BP2) 42.02 m Breadth 11.80 m Draught F: 4.26 m - A: 4.57 m Built - 1981, Halifax, Nova Scotia Propulsion - One eight-cylinder marine diesel engine, capable of 3,000 BHP (2,207 kW), driving a controllable-pitch propeller Owners - National Sea Products Ltd. Halifax, Nova Scotia Complement - 15 crew members plus one DFO observer 1.2 Description of the Vessel The CAPE BRIER is a conventional stern trawler with the fish-processing spaces and fish holds amidships. The navigation bridge and crew accommodation are forward, and the machinery space aft. 1 Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System (SI) of units. 2 See Glossary for all abbreviations, acronyms, and definitions. 3 All times are ADT (Coordinated Universal Time (UTC) minus three hours) unless otherwise stated. 1.3 History of the Voyage The CAPE BRIER departed Lunenburg, Nova Scotia, at about 10303, 11 October 1993, to fish for ocean perch off the south coast of Newfoundland. On the afternoon of 13 October, the visibility was reduced in rain with seas running at some 2 to 3 m in near-gale force winds as the CAPE BRIER hauled the trawl net back in after a tow in a position some 10 miles to the west of Burgeo Bank, Newfoundland. The vessel was estimated to be rolling as much as 30 when the net was brought on to the stern ramp. At about 1340, five crew members were in attendance at the ramp-side bulwarks, three to port, and two to starboard. The mate was operating the trawl winch from the controls located at the after end of the bridge, and all those involved in the haul-back operation had a clear and unobstructed view of the stern ramp and were clear of the trawl warps. On a roll to port, the chain securing a spare trawl door parted and the door, a mid-water door that had been stowed upright against the ship-side bulwark on the starboard side, fell inboard. As the door fell, it struck one of the two crew members positioned at the side of the stern ramp, pinning him against the ramp-side bulwark. On the next roll, the trawl door shifted and another crew member was able to pull the victim clear of the door. The haul-back of the net was stopped and aid to the injured crew member was immediately begun. Despite the crew's efforts, the crew member was pronounced dead after radio consultation with a doctor in Halifax, Nova Scotia. 1.4 Injuries to Persons The crew member who was struck by the trawl door was fatally injured. 1.5 Personnel Experience and Qualifications The master of the CAPE BRIER had 19 years' seagoing experience on fishing vessels. He had been a master for 16 years and master on the CAPE BRIER since 1989. The mate had 15 years' seagoing experience and had been sailing as mate for 5 years on the CAPE BRIER. The victim had been employed on fishing vessels for 14 years and on the CAPE BRIER for 4 1/2 years. The master held a Fishing Master Class I Certificate, and the mate held a Fishing Master Class II Certificate. The victim did not hold any formal marine qualification nor was he required to by regulation. 1.6 Vessel Certification A Steamship Inspection Certificate (SIC 31) had been issued to the CAPE BRIER and was valid until 11 June 1994 for Home Trade Class I voyages. 1.7 Weather Information The Meteorological and Oceanographic Centre in Halifax provided the following meteorological information for the area in which the CAPE BRIER was operating: Between 0900 and 1500, the wind shifted from easterly to south-easterly at 25 to 35 knots with reports of the wind reaching 45 knots in some areas. The visibility was two to five nautical miles in rain. Seas were forecast and reported to be 3 to 3.5 m. At 1300, the CAPE BRIER recorded the wind as SE force 7 (28 to 33 knots), visibility one nautical mile in rain with seas to 2 m. 1.8 Trawl Door Stowage When used, mid-water trawl doors are launched from trawl gallows on the vessel's quarters. The CAPE BRIER was built with recesses in the ship-side bulwarks on each quarter where these doors could be conveniently stowed when not required. However, changes in the fishing industry prompted the owners to have their vessels use larger mid-water trawl doors. These larger doors (some 8 m2 in area and weighing 1,100 kg) would not fit in the designed recesses in the bulwarks, and the recesses were then used for spare bottom doors. The mid-water doors were stowed at the discretion of the master of each vessel. On the CAPE BRIER, the doors were stowed against the ship-side bulwarks, inboard of the original stowage recesses. 1.9 Securing of Trawl Doors The mid-water trawl doors were reportedly stowed upright, with one side resting on the deck at a slight angle to the ship-side bulwarks. The stowage arrangement is depicted in Appendix A. The doors were secured by means of a chain which led from the end of the centre web of the door over the upper edge of the door and down to the chain securing the spare bottom trawl door in the bulwark recess. No turn-buckle or other tightening device was incorporated in the securing chain and there was no chocking arrangement to secure the lower edge of the door which was in contact with the deck. Scratch marks were noted on the deck in the area. Coupling links were used for all securing chain connections. During the investigation, the securing chain and the coupling link used in the connection to the bulwark were recovered, but all parts of the coupling link used in the connection to the trawl door were missing. 1.10 Coupling Links Coupling links are commonly used on fishing vessels because they are a quick and effective means of joining chains to each other, to securing points, or to other pieces of gear such as hooks. A coupling link resembles a studded chain link and is made up of two symmetrical semi- circular body forgings joined by an alloy load pin which is retained in position by a stud assembly. The unit is put together by driving the load pin into the stud assembly when all the components are in place. The unit then holds together because of the friction fit of the load pin in the stud assembly. The onus is on the user to replace a coupling link when the fit becomes slack. The evidence was that it would not be unusual to replace 12 or more coupling links during a typical fishing trip. 1.11 Laboratory Analysis Two 16 mm (5/8-inch) coupling links and chain samples from the mid-water trawl door securing arrangement were sent to the TSB Engineering Laboratory for analysis. The two coupling links from the securing arrangement and a new coupling link of the same size were tested to destruction. The laboratory report on these tests shows that, despite the fact that the stud assembly of one unit was in an advanced stage of degradation and the load pin was considerably reduced in diameter within the stud assembly, all three coupling links failed at a load in excess of the manufacturer's specified minimum breaking load of some 32,800 kg (72,300 lb). The chain samples also showed signs of corrosion. However, in spite of the corrosion layer being up to 1 mm thick, the interior of the chain was found to be sound.